In this specification, where a document, act or item of knowledge is referred to or discussed, this reference is not an admission that the document, act or item or knowledge or any combination thereof was at the priority date:    (i) part of common general knowledge; or    (ii) known to be relevant to an attempt to solve any problem with which this specification is concerned.
The creation of a medical record for a patient is an essential aspect of medical treatment. As known by those skilled in the art, records typically include a variety of information such as doctor and nursing notes regarding the patient's complaints and symptoms, diagnoses, treatments and procedures administered, allergies, medicines the patient has been taking, medicines that are newly prescribed as well as patient demographic information.
Medical records allow physicians who treat a patient in the future to gain background regarding the patient's condition, in a continual process of storytelling and retelling that sometimes extends over a patient's entire lifetime.
Many attempts have been made to create a standardised nomenclature for diagnoses, treatments, medical procedures, medications, and other medical services for inclusion in medical records. One system is the International Classification of Diseases (ICD), which is a classification structure that provides rules for assigning numeric codes that specify diseases, injuries, the causes of these, medical findings, and other factors affecting patient care, as well as codes for surgical, diagnostic, and therapeutic procedures. Other classification systems include the Systemized Nomenclature of Medicine Clinical Terms (SNOMED CT)—which provides detailed and specific classification codes for clinical information and reference terminology, the Logical Observation Identifiers Names and Codes (LOINC)—for identifying laboratory observations—and the International Classification of Primary Care (ICPC).
The move from paper-based to fully electronic medical records has been underway for a number of years and there are many electronic medical record administration systems available. An intractable problem with these systems, however, is a lack of interoperability, being the ability of two or more systems or components to exchange information and to use the information that has been exchanged as defined by IEEE 90.
Of course, interoperability would be less of an issue if all medical data was coded into medical records using a common coding system and utilisation of a common medical record architecture, in the same manner as an ASCII file for the exchange of text. This however, is an unrealistic goal, at least at the present time. In order to ameliorate difficulties arising from the lack of interoperability, maps have been established to allow for data conversion directly from one coding system into another. In addition ‘health message protocols’, such as HL7 or PIT, allow for the communication of portions of medical records from one system to another by specifying the coding system in a field of the communicated data structure, with other fields of the structure populated with the requisite medical codes. Of course, the data must still be converted into the native coding system of the recipient system by utilising a conversion map (as referred to above) before it can be processed by the recipient system.
High level conversion maps are not perfect because of, amongst other things, the differing meanings captured by the codes of each system, and also because of a lack of equivalent codes between systems. This less than perfect mapping between coding systems can result in information being lost during the process of conversion. It is thus an object of the present invention to allow the exchange of medical records between systems using differing coding systems and record architectures, that reduces the likelihood of information loss occuring.